HEALTH officials have been forced to make changes following the death of a paranoid schizophrenic who jumped from the roof of a Winchester car park.

As previously reported, Carl Lewis was found by medical staff at the entrance of the Education Centre of the Royal Hampshire County Hospital on April 16, last year. An inquest last month heard he should not have been allowed to leave Melbury Lodge, where he was a patient.

A spokesman for Southern Health NHS Foundation Trust has said Mr Lewis's death has resulted in a number of key changes at the facility, including ensuring the correct paperwork is completed prior to any patient leaving - a vital piece of evidence which came to the light during the hearing.

The 42-year-old, who was a patient at Melbury Lodge, was rushed to A&E but died from multiple skull fractures a short while later.

During the inquest in Winchester, the jury was told how Mr Lewis was technically not permitted out of the clinic the day he plummeted to his death because he'd refused to take medication for his paranoid schizophrenia.

Dr Guy Powell, consultant psychiatrist at Melbury Lodge, told the hearing: “Technically he should never have been allowed out of the hospital. He had been going out of the hospital on regular occasions. It would have been unreasonable to stop him from going out. We cannot gratuitously deny people liberty.”

The Southern Health spokesman added: “Following the conclusion, our thoughts continue to be with the family and friends of Mr Lewis at this difficult time. We had been working with Mr Lewis for a number of years and he was well known to many of our staff. Mr Lewis would often present to our teams informally when he felt he couldn't manage his condition and our staff were familiar with his routines and often tried to accommodate these as part of his recovery.

“It is vital that our organisation learns from this incident. As a result of this case we have already put in a place a number of key changes which include: a new system in place to ensure the correct paper work is completed and sign-off has taken place before any patient is granted leave, [and] improvements to paper work which include larger areas for clinicians to record more detailed information about a patients mental state for leave requests and the colour coding of specific forms to enable staff to access key information more efficiently.

“With hindsight it is clear these improvements would not have prevented the tragic outcome. Mr Lewis was not behaving in a way that would cause concern from the professionals supporting him, and following an assessment would very likely have been granted leave, which was a regular part of his routine and important to his recovery.

“We fully accept the coroner's conclusion, which supports our own internal findings. We are confident that the changes we have made mean our staff will be better able to view a patient's journey through our services and asses their current state of health when granting leave.”